CLIENT INTAKE FORM

What Breathwork Is
 

 

Breathwork is a guided practice using conscious breathing patterns.

Sessions may create physical sensations, emotional responses, and psychological insights.

 

 

What Breathwork Is NOT
 

 

• Not psychotherapy

• Not medical treatment

• Not a replacement for psychiatric care

• The facilitator is not acting as a doctor or therapist

 

 

Possible Physical + Emotional Responses
 

 

Clients may experience:

• tingling

• temperature changes

• muscle tightness

• crying or emotional release

• dizziness

• mood shifts

• resurfacing memories

• catharsis or deep relaxation

 

These reactions can be intense but are generally temporary.

 

 

 

CLIENT RESPONSIBILITIES
 

 

By signing, you agree to:

• communicate if you feel overwhelmed

• stay within your physical limits

• consult a doctor if unsure about medical conditions

• avoid sessions while intoxicated or withdrawing

• take full responsibility for your emotional and physical well-being

• participate from a safe, private environment (for virtual sessions)

 

 

 

 

CONFIDENTIALITY:

 

 

All personal information is confidential except when legally required (harm to self/others, abuse, court odrder).

Voluntary Participation

I understand I am choosing to participate voluntarily and may stop at any time.
Assumption of Risk

I acknowledge breathwork may trigger physical and emotional responses. I accept full responsibility for my participation.
Not a Substitute for Care

I understand breathwork is not medical treatment or therapy.
Limited Release

I release Vitkovich Integrative Services LLC and Shane Vitkovich from liability for unexpected emotional experiences or non-medical reactions during sessions.

(I understand this does NOT replace the full legal liability waiver, which I will sign separately.)
 

Before you hit submit, remember you must also complete the Liability Waiver and Terms & Cancellation forms. Links will appear on the next screen.